November/December 2021

The Last Word: Let’s Treat All Our Patients Like Family by Offering Advanced Gold-Standard Surgery
By Lance Patrick Walsh, MD, PhD
Today’s Geriatric Medicine
Vol. 14 No. 6 P. 34

My family member, like most men in their 70s, had an enlarged prostate, also called benign prostatic hyperplasia (BPH). About one-half of men have the condition by age 60, and the prevalence reaches about 90% after age 80.1 Many cases are controlled with medication, but patients may need surgery in cases where medical symptoms are intolerable, chronic catheterization is required, or the prostate is very large.

Because BPH is a widespread problem that can significantly affect health and quality of life, every urologist treats it, but too few surgeons are performing a safe, minimally invasive gold-standard procedure called holmium laser enucleation of the prostate (HoLEP). When my family member’s urologist recommended HoLEP for his large prostate, the doctor referred him to me because I’m the only HoLEP surgeon in the region.

A Pervasive Problem
BPH decreases quality of life. Patients can’t sit through a baseball game, take a long trip, or get a good night’s sleep because they’re experiencing urinary frequency, urgency, hesitancy, or a slow or intermittent urine flow. Medications can control symptoms for most patients with mild to moderate BPH. If medications are ineffective, we evaluate whether a patient is a good candidate for a minimally invasive in-office procedure.

For many men, including my family member, the prostate can become very large (100 to 200 cc). Medications can become ineffective, and an in-office procedure is not an option. His surgical options were HoLEP, open or robotic prostatectomy, or transurethral resection of the prostate. Open prostatectomy is an invasive procedure requiring multiple days in the hospital. Robotic prostatectomy is less invasive, but patients have multiple port incisions and typically stay overnight. Transurethral resection of the prostate has no incisions, but it can be difficult to remove enough tissue from very large prostates, and patients are hospitalized.

HoLEP, in which a laser with “Moses effect” pulse modulation is used to remove the prostate, is a urethroscopic procedure with no external incisions. Because HoLEP causes less bleeding than many other procedures, patients such as my family member who take anticoagulants can have the procedure without stopping their medication, and most patients can go home catheter-free the same day.2,3 Complication rates are low, and the effects are lasting.4-6

The Issue of Proximity
My family member had a good urologist who recommended HoLEP as the best choice for his case, but no urologists in his region offer the procedure. The doctor referred him to me, just as he does with other patients, because I’m the closest expert doing HoLEP.

My family member trusted me and was comfortable about the surgery, but I was initially reluctant. I discussed it with his children and wife, and they offered their support. For me, the decision came down to the fact that no one else in the area could do HoLEP, and it was his best choice because the procedure excels with large prostates.

Surgery went smoothly with no complications. My family member returned home the same day. His symptoms were controlled without medication within one to two weeks. He is very pleased to no longer have urinary urgency, frequency, and discomfort disrupting his life.

For me, the experience highlighted the need for more urologists and hospitals to offer HoLEP. More and more physicians are acknowledging that this is a superior approach for the right candidates, but more of those surgeons need to perform HoLEP. All patients—especially those who are older and more likely to have multiple health challenges—deserve to be treated like family, close to home.

— Lance Patrick Walsh, MD, PhD, is a urologist at Titus Regional Medical Center in Mount Pleasant, Texas, where he helped launch the Advanced Urology Institute, a comprehensive primary care urology clinic and regional referral center for cutting-edge surgeries. The AUI is a Lumenis Center of Excellence, where Walsh uses a MOSES holmium laser to treat patients with BPH and kidney stones.

References
1. What is benign prostatic hyperplasia (BPH)? American Urological Association website. https://www.urologyhealth.org/urologic-conditions/benign-prostatic-hyperplasia-(bph). Updated May 2019. Accessed August 10, 2021.

2. Rivera M, Krambeck A, Lingeman J. Holmium laser enucleation of the prostate in patients requiring anticoagulation. Curr Urol Rep. 2017;18(10):77.

3. Agarwal DK, Large T, Tong Y, et al. Same day discharge is a successful approach for the majority of patients undergoing holmium laser enucleation of the prostate. Eur Urol Focus. 2021;S2405-4569(20)30320-30325.

4. Cornu JN, Ahyai S, Bachmann A, et al. A systematic review and meta-analysis of functional outcomes and complications following transurethral procedures for lower urinary tract symptoms resulting from benign prostatic obstruction: an update. Eur Urol. 2015;67(6):1066-1096.

5. Sun F, Sun X, Shi Q, et al. Transurethral procedures in the treatment of benign prostatic hyperplasia: a systematic review and meta-analysis of effectiveness and complications. Medicine (Baltimore). 2018;97(51):e13360.

6. Gilling PJ, Aho TF, Frampton CM, et al. Holmium laser enucleation of the prostate: results at 6 years. Eur Urol. 2008;53(4):744-749.